Reseller

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Reseller Application

General info

Company Name

Name*

Email*

Work Phone*

Fax

Address*

City*

State

Zip Code*

Company Info

Legal Structure

Year Founded

# of Locations

Annual Revenues

Total Full Time Employees

Total Sales/Service Employees

Vertical Markets Served (Check all that apply)

Medical	Dental	Accounting/Legal
Small Business	Other

Product

What Practice Management System do you sell?

What EMR or other Clinical software do you sell?

What other software do you sell?

Services

Do you provide networking, hardware, support and training services

Yes

No

Customer Base

Total # of customers

Number of Healthcare Customers